13 General introduction (US) when she gives a speech in different contexts (see Figure 1.1). When she experiences that she is not being rejected repeatedly, she no longer expects social rejection to occur when giving a public speech. Avoidance behavior Avoidance and safety behaviors in SAD As described in the different psychological models (Clark & Wells, 1995; Heimberg & Rapee, 1997; Hofmann, 2007; Spence & Rapee, 2016; Wong & Rapee, 2016), avoidance behavior plays a crucial role in the maintenance of SAD. As mentioned above, avoidance is a behavioral strategy to prevent exposure to the feared situation, which can take different forms. For example, an individual with SAD could completely avoid social situations such as a party, a speech or a job interview. Also, avoidance behavior can take more subtle forms in which individuals aim to reduce their distress or hide it, such as avoiding eye contact, speaking quietly, or taking somebody with them to the feared situation (those types of more subtle avoidance behaviors can also be classified as safety behaviors, Cuming et al., 2009; Wells et al., 1995). Although avoidance can be adaptive in threatening situations (e.g., running away when being attacked by a dangerous animal), and can result in temporary relief in the short run, avoidance is unnecessary in absence of real danger and can become maladaptive in the long run. Critically, systematic avoidance behavior hinders the individual to learn that fears are unsubstantiated. Rose can never experience that she can chat at a party and might not be rejected if she avoids going there at all. The same is true when she uses safety behaviors such as looking away when people make eye contact. Moreover, successful avoidance usually results in a temporary reduction in anxiety and is therefore reinforcing and persistent (Wong & Moulds, 2011). As such, social avoidance behavior is a major factor that maintains fear of social situations in individuals with SAD (Arnaudova, Kindt, Fanselow, & Beckers, 2017; Clark & Wells, 1995). Therefore, reducing avoidance behavior is the core target of treatment for SAD. Safety and subtle avoidance behaviors are typically discouraged during exposure sessions through modeling by the therapist and by providing explicit instructions (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014b; Hofmann & Otto, 2017), since they may also hamper the efficacy of exposure therapy (Wells et al., 1995). A therapist might for instance stimulate Rose not to use notes during the speech neither holding something in her hands, stimulating effective approach behavior. Otherwise, Rose may feel that she could only give the speech because of her notes in her hand (Piccirillo, Taylor Dryman, & Heimberg, 2016). In fact, the use of safety behaviors could increase the likelihood of 1
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